Merritt Personal Lines Manual: How the Policy Handles In-Patient Care
HOSPITAL IN-PATIENT COVERAGE
The benefits for confinement in a hospital are:
(1) room (other than private room), board and general nursing care and
(2) miscellaneous hospital services.
HOSPITAL ROOM -- For each day of confinement in one period of confinement, we will pay up to the amount shown on page ____ for the insured person. See page ____ for the number of days we will pay during one period of confinement.
MISCELLANEOUS HOSPITAL SERVICES -- For any one period of confinement, we will pay up to the maximum amount shown on page ____ for the insured person.
Hospital inpatient coverage provides benefits for charges a hospital makes on its own behalf for such things as room and board, nursing care and miscellaneous services. Benefits for room and board are limited to the semi-private room rate, a maximum dollar amount per day and a maximum number of days of confinement. Benefits for miscellaneous services are also limited to a maximum dollar amount. The maximum benefits are shown in the benefit schedule which is usually found at the beginning of the policy.
An example: You have hospital inpatient coverage with benefits of $300 a day for a maximum of 365 days. You're confined for 10 days in a private room. The hospital charges $325 a day for the private room and its semi-private room rate is $250. Your policy will only pay $2,500 -- the semi-private room rate for 10 days. There is no coverage for amounts above the semi-private room rate, even if the daily maximum benefit is higher.
Another example: With the same coverage, you're confined in a semi-private room for 10 days and the hospital charges $325 a day for the semi-private room. Your policy would pay $3,000 in this case because the daily maximum benefit amount would apply.
Hospital services do not include professional services of a radiologist, pathologist, anesthesiologist, nurse, physician or surgeon.
Benefits are payable in a hospital or in a mental hospital (which is licensed by the State) for the treatment of a mental, emotional or nervous disorder, alcoholism or drug dependency. We will pay the benefits which we would otherwise pay for the expense incurred in the treatment of a covered sickness. We will not pay for more than 30 days of active treatment in any one policy year.
Confinement in a hospital or a mental hospital, means:
(1) an insured person is confined to a hospital room for 24 hours or more and
(2) a daily charge is made.
In order for a hospital confinement to be covered:
(1) it must be for an injury or sickness
(2) it must begin while this coverage is in force for the person confined
(3) it must be at the direction of and under the supervision of a physician or surgeon.
Hospital inpatient benefits apply to charges made by a hospital as an entity (for room, board, overhead expenses, supplies, etc.). For this reason these benefits do not apply to any separate charges made by a radiologist, pathologist, anesthesiologist, nurse, physician or surgeon for professional services. (As you will see, separate optional coverages are available for services provided by doctors, nurses and surgeons.)
Inpatient benefits are provided when an insured is confined for the treatment of mental, emotional or nervous disorders, alcoholism and drug dependency. But benefits for these conditions are limited to 30 days of treatment in any one policy year.
"Confinement" means that an insured is confined in a hospital or mental hospital for 24 hours or more and a daily charge is made. In order for a period of confinement to be covered, it must occur because of injury or sickness, begin while coverage is in force for the insured person and be at the direction of a physician or surgeon.
